Meeting the Needs of the Community: A System for Redesigning Care

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Meeting the Needs of the Community A System for
Redesigning Care

• Mike Hindmarsh
• Hindsight Healthcare Strategies

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Mrs. C We all know one

• Ms. C is a 68yo woman with cough and shortness of
  breath and risk factors for Type II diabetes.
  She calls her doctor who cannot see her until the
  following week.
• Two days later she is hospitalized with shortness
  of breath. She is dxed with CHF, discharged on
  captopril, no added salt diet with
  encouragement to see her MD in three weeks
• When she sees her MD, he does not have
  information about the hospitalization
• PE reveals rales, S3 gallop, edema and possible
  depression
• Ms. C is told she has a little heart failure,
  encouraged not to add salt, and Captopril is
  increased. Her depression is not addressed.
• She is told to call back if she is no better
• Two weeks later Ms. C calls 911 because of severe
  breathlessness and is admitted.
• Fuller history in the hospital reveals that she
  has been taking the Captopril prn because it
  seems strong, and she has never added salt to
  her diet, so her diet hasnt changed.
• Further tests reveal elevated blood glucose. She
  is warned of impending diabetes.
• She is discharged feeling ill and frightened.

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Four Biggest Worries About Having A Chronic
Illness (Age 50 )

1. Losing independence
2. Being a burden to family or friends
3. Affording medical care

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The Increasing Burden of Chronic Illness
For Example Patients with Diabetes Need
Additional Diagnoses 45
Functional Limits 50
gt 2 Symptoms 35
Not Good Health Habits 30

• Arthritis (34), obesity (28), hypertension
  (23),cardiovascular (20), lung 17)
• Physical (31), pain (28), emotional (16),
  daily activities (16)
• Eating/weight (39), joint pain (32), sleep
  (25), dizzy/fatigue(23), foot
• (21), backache (20)

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Differences between acute and chronic
conditions
(Holman et al, 2000)
Acute disease Chronic Illness
Onset Abrupt Generally gradual and often insidious
Duration Limited Lengthy and indefinite
Cause Usually single Usually multiple and changes over time
Diagnosis and prognosis Usually accurate Often uncertain
Intervention Usually effective Often indecisive adverse effects common
Outcome Cure possible No cure
Uncertainty Minimal Pervasive
Knowledge Prof.s - knowledgeable Patients - inexperienced Prof.s and patients have complementary knowledge and exp.s
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Figure 2 Care Gap for Chronic Conditions
Adherence to recommended care is low for chronic
conditions
of Recommended Care Received
Source McGlynn et al. NEJM 2003
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Figure 3 The toll on patients is high US Data
CONDITION SHORTFALL IN CARE AVOIDABLE TOLL
Diabetes Average blood sugar not measured for 24 29,000 kidney failures 2,600 blind
Colorectal cancer 62 not screened 9,600 deaths
Pneumonia 36 of elderly didn't receive vaccine 10,000 deaths
Heart attack 39 to 55 didn't receive needed medications 37,000 deaths
Hypertension Less than 65 received indicated care 68,000 deaths
Source Elizabeth McGlynn, et al. The Quality of
Health Care Delivered to Adults in the US. NEJM
2003 3482635-45
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Systems are perfectly designed to get the
results they achieve
The Watchword
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Problems with Current Disease Management Efforts

• Emphasis on physician, not system, behavior
• Lack of integration across care settings
  hindering quality care
• Characteristics of successful interventions
  werent being categorized usefully
• Commonalities across chronic conditions
  unappreciated

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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Model Development 1993 --

• Initial experience at GHC
• Literature review
• RWJF Chronic Illness Meeting -- Seattle
• Review and revision by advisory committee of 40
  members (32 active participants)
• Interviews with 72 nominated best practices,
  site visits to selected group
• Model applied with diabetes, depression, asthma,
  CHF, CVD, arthritis, and geriatrics

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Essential Element of Good Chronic Illness Care
Prepared Practice Team
Informed, Activated Patient
Productive Interactions
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What characterizes a prepared practice team?
Prepared Practice Team
At the time of the visit, they have the patient
information, decision support, people,
equipment, and time required to deliver
evidence-based clinical management and
self-management support
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What characterizes an informed, activated
patient?
Informed, Activated Patient
Patient understands the disease process, and
realizes his/her role as the daily self manager.
Family and caregivers are engaged in the
patients self-management. The provider is
viewed as a guide on the side, not the sage on
the stage!
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What is a productive interaction?
Informed, Activated Patient
Prepared Practice Team
Productive Interactions

• Assessment of self-management skills and
  confidence as well as clinical status
• Tailoring of clinical management by stepped
  protocol
• Collaborative goal-setting and problem-solving
  resulting in a shared care plan
• Active, sustained follow-up

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Self-Management Support

• Emphasize the patient's central role
• Use effective self-management support strategies
  that include assessment, goal-setting, action
  planning, problem-solving, and follow-up
• Organize resources to provide support

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Delivery System Design

• Define roles and distribute tasks amongst team
  members
• Use planned interactions to support
  evidence-based care
• Provide clinical case management services
• Ensure regular follow-up
• Give care that patients understand and that fits
  their culture

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Features of Case Management

• Regularly assess disease control, adherence, and
  self-management status
• Either adjust treatment or communicate need to
  primary care immediately
• Provide self-management support
• Provide more intense follow-up
• Provide navigation through the health care
  process

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Decision Support

• Embed evidence-based guidelines into daily
  clinical practice
• Integrate specialist expertise and primary care
• Use proven provider education methods
• Share guidelines and information with patients

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Clinical Information System

• Provide reminders for providers and patients
• Identify relevant patient subpopulations for
  proactive care
• Facilitate individual patient care planning
• Share information with providers and patients
• Monitor performance of team and system

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Health Care Organization

• Visibly support improvement at all levels,
  starting with senior leaders
• Promote effective improvement strategies aimed at
  comprehensive system change
• Encourage open and systematic handling of
  problems
• Provide incentives based on quality of care
• Develop agreements for care coordination

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Community Resources and Policies

• Encourage patients to participate in effective
  programs
• Form partnerships with community organizations to
  support or develop programs
• Advocate for policies to improve care

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Advantages of a General System Change Model

• Applicable to primary and secondary preventive
  issues, prenatal and pediatric, mental health and
  other age-related chronic care issues
• Once system changes in place, accommodating new
  guideline or innovation much easier
• Fits well with other redesign initiatives such
  as improved access
• Approach is being used comprehensively in
  multiple care settings and countries

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Research and QI Findings about The Chronic Care
Model
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Organizing the Evidence

1. Randomized controlled trials (RCTs) of
   interventions to improve chronic care
2. Studies of the relationship between
   organizational characteristics quality
   improvement
3. Evaluations of the use of the CCM in Quality
   Improvement
4. RCTs of CCM-based interventions
5. Cost-effectiveness studies

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1 RCTs of interventions to improve chronic care
results

• Complex, integrated care, disease
  management programs show positive effects on
  quality of care
• Consistently powerful elements include team
  care, case management, self-management support

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2 Studies of the Relationship between
Organizational Characteristics Quality
Improvement

• Diabetes, preventive services, asthma, chronic
  disease care
• Organizational characteristics associated with
• successful implementation of quality improvement
  programs
• improved health outcomes of patients

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2 Studies of the Relationship between
Organizational Characteristics Successful
Implementation of QI Projects

• Common organizational characteristics across
  studies
• Organized teams, including physicians, involved
  in quality improvement
• Reminder systems patient registries
• Reporting data to external organizations
• Formal self-management programs
• Others Characteristics associated with process
  improvement include
• Receiving income, recognition, or better
  contracts for quality
• Improved IT infrastructure
• Large size
• Receiving capitation payments
• Utilizing guidelines supported by academic
  detailing
• Primary care orientation

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3 Evaluations of the Use of CCM in Quality
Improvement

• Largest concentration of literature
• RAND Evaluation of ICIC
• Wide variety in quality and type of evaluation
  design
• Majority of studies focus on diabetes

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3 RAND Evaluation of Chronic Care Collaboratives

• Two major evaluation questions1. Can busy
  practices implement the CCM?2. If so, would
  their patients benefit?
• Studied 51 organizations in four different
  collaboratives, 2132 BTS patients, 1837 controls
  with diabetes, CHF, asthma
• Controls generally from other practices in
  organization
• Data included patient and staff surveys, medical
  record reviews

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3 RAND Findings Patient Impacts

• Diabetes pilot patients had significantly reduced
  CVD risk (pilotgtcontrol), resulting in a reduced
  risk of 1 cardiovascular disease event for every
  48 patients exposed.
• CHF pilot patients more knowledgeable and more
  often on recommended therapy, had 35 fewer
  hospital days and fewer ER visits
• Asthma and diabetes pilot patients more likely to
  receive appropriate therapy.
• Asthma pilot patients had better QOL

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3 Non-RAND Evaluations of CCM Implementation

• In general, those studies with greater fidelity
  to the CCM showed greater improvements
• All but one showed improvement on some process
  measures
• Most showed improvement on outcomes empowerment
  measures, as well.
• Sustainability implementation of all CCM
  elements were challenges
• Physician staff must be motivated to change

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Successes of Teams in Collaboratives The
Benefit of Organized Chronic Care

• 1.5 - 2 times as many patients with major
  depression will be recovered at six months
• Inner city kids with moderate to severe asthma
  have 13 fewer days per year with symptoms
• Readmission rates of patients hospitalized with
  CHF will be cut nearly in half

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Premier Health Partners

• Dayton, Ohio
• 100 physicians in 36 practices
• Change began in one practicespread throughout
  system
• ACE-inhibitors for albuminuria was 38 in 1999
  and 80 in 2001
• A1c lt 7 was 42 in 1999 and 70 in 2001

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UKPDS trend

• There are currently177,401 patients in the
  diabetes registries with 77 of the organizations
  reporting registry size.
• This measure reflects the average HbA1c of those
  having at least one HbA1c in the last 12 months.

Source of data reported 1/1/05
Jlangley_at_apiweb.org Slide preparation
chupke_at_nibcomp.com 2-2-05
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4 Randomized Controlled Trials (RCT) of
CCM-based Interventions

• 6 RCTs covering asthma, diabetes, bipolar
  disorder, comorbid depression oncology, and
  multiple conditions
• 5 in the US disease specific, 1 in Australia
  multiple diseases
• Practice-level randomization
• Varying levels of disease severity mild to
  severely ill highly comorbid

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4 RCTs of CCM-based interventions Results

• All but one study shows that implementation of
  the Chronic Care Model significantly improves
  process and outcome measures compared to controls
  and when included in the trial less intensive
  interventions (e.g. physician training alone)
• Often CCM implementation is linked with improved
  patient empowerment education scores, as well
• Active team motivation to change may be an
  important factor in predicting success

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5 Cost Effectiveness Study Results

• Some evidence that improved disease control can
  reduce cost, especially for heart disease
  uncontrolled diabetes
• Achieving cost-savings depends on the disease
  management strategies employed
• Features of the healthcare market place
  including displacement of payoffs in time and
  place and failure to pay for quality act as
  barriers to a business case for quality

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What have we learned?

• Start where you willing
• Take small steps
• Move quickly
• Learn from failures
• Data, data, data

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Primary Care

• Build the team structure
• Obtain guidelines
• Collect some baseline data on the population
• Set performance measures and targets
• Call in patients for planned visits
• Set self-mgmt goals at the visit
• Conduct follow up on shared care plan

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The Mrs. C We Want to Know

• Mrs. C is discharged after her first bout of
  breathlessness with information about CHF, risk
  factors for diabetes, and assurance of rapid PCP
  follow-up
• The discharge nurse notes Mrs. Cs conditions and
  care in the EHR and then sends an email to PCPs
  office about her recent hospitalization.
• The primary care nurse ensures the physician sees
  the information and calls Mrs. C to schedule a
  follow-up within 48 hours. Mrs. C is added to
  the care teams registry which prompts team to
  her future care needs.
• Mrs. C is scheduled for 30 minutes 15 minutes
  with her physician and 15 minutes with the nurse
  (or medical asst.). The physician explains CHF
  and diabetes to her. He orders the appropriate
  diagnostic test for diabetes and assures her that
  all will be fine recognizing her fear and shock.
  He closes the loop with her to make sure she
  understood his recommendations and then briefly
  explained the concept of self-management support.
  
• Mrs. C then visits with the nurse who steps her
  through a collaborative goal setting and action
  planning process. While Mrs. C is a bit
  overwhelmed, she is assured that her care team
  will follow-up in the next couple of days by
  phone to make sure she understands her clinical
  and self-management care plan and to report on
  the results of diabetes test.
• The nurse calls within 48 hours and informs Mrs.
  C that she should be able to manage her blood
  sugar by better diet and exercise. She reviews
  the CHF medications with Mrs. C and adjust dosage
  since it seems to be bothering her.
• She is scheduled for a follow-up visit in one
  week to discuss her blood glucose in more depth.
  She is encouraged to call her team should she
  have any concerns or symptoms in the meantime.
• Mrs. C understands the hard work she needs to do
  to manage her conditions but is thankful for such
  a caring team.

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For more information please see our web site
www.improvingchroniccare.org Or contact me at
hindmarsh.m_at_ghc.org
Thank you